Provider Demographics
NPI:1093791816
Name:KELLER, BRIAN PATRICK (DPM)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:PATRICK
Last Name:KELLER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:841 STERLING PKWY
Mailing Address - Street 2:STE 130
Mailing Address - City:LINCOLN
Mailing Address - State:CA
Mailing Address - Zip Code:95648-7324
Mailing Address - Country:US
Mailing Address - Phone:916-434-6410
Mailing Address - Fax:916-434-6310
Practice Address - Street 1:841 STERLING PKWY
Practice Address - Street 2:STE 130
Practice Address - City:LINCOLN
Practice Address - State:CA
Practice Address - Zip Code:95648-7324
Practice Address - Country:US
Practice Address - Phone:916-434-6410
Practice Address - Fax:916-434-6310
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-22
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4185213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E41851Medicaid
CADE0031OtherPALMETTO GBA RAILROAD MED
CADE0031OtherPALMETTO GBA RAILROAD MED
CA000E41851Medicaid
CA4244540001Medicare NSC